JLM929
Networker
here is a copy of an exam for a right shoulder. I believe this would be a detailed exam any disagreements? and if so why?
thanks
Ht: 5 ft 5 in Wt: 200 lbs BMI: 33.3 RR: 14 Document Review Discussed the following
Physical Exam Patient is a 74-year-old female.
Constitutional: General Appearance: healthy-appearing, NAD, and normal body habitus.
Psychiatric: Orientation: oriented to time, place, and person. Mood and Affect: normal mood and affect and active and alert.
Cardiovascular System: Arterial Pulses Right: radial normal, ulnar normal, and capillary refill test normal. Arterial Pulses Left: radial normal, ulnar normal, and capillary refill test normal. Edema Right: none. Edema Left: none.
Respiratory: Lungs: Clear to auscultation.
Skin: Right Upper Extremity: normal. Left Upper Extremity: normal.
C-Spine/Neck: Active Range of Motion: no crepitus or pain elicited by motion and flexion normal, extension normal, rotation normal, and lateral flexion normal. Passive Range of Motion: flexion normal, extension normal, rotation normal, and lateral flexion normal. Tests Left: quadrant test negative and Spurling's test negative.
Shoulder Inspection: Inspection Right: no erythema, induration, swelling, warmth, or long head of biceps deformity and AC prominence normal. Inspection Left: no erythema, induration, swelling, warmth, or long head biceps deformity and AC prominence normal.
Shoulder Palpation: Bony Palpation Right: no tenderness of the acromioclavicular joint, the bicipital groove, the greater tuberosity, the spine, the clavicle, the coracoid process, the suprasternal notch, the sternoclavicular joint, or the scapula. Bony Palpation Left: no tenderness of the spine, the clavicle, the coracoid process, the suprasternal notch, the sternoclavicular joint, or the scapula and tenderness of the acromioclavicular joint, the bicipital groove, and the greater tuberosity. Soft Tissue Palpation Right: no tenderness of the subacromial space or the rotator cuff insertion. Soft Tissue Palpation Left: no tenderness of the subacromial space or the rotator cuff insertion.
Shoulder Range of Motion: Active Range of Motion Right: external rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; internal rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; and forward flexion normal, abduction normal, extension normal, and no sudden ROM end-point with pain. Active Range of Motion Left: external rotation at 0 deg. of abduction 30 deg. and 90 deg. of abduction 30 deg.; forward flexion 60 deg., internal rotation at 90 deg. of abduction 30, abduction 60, extension 90 deg., and sudden ROM end-point with pain; and internal rotation at 0 deg. of abduction normal. Passive Range of Motion Right: external rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; internal rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; and forward flexion normal, abduction normal, extension normal, and no sudden ROM end-point with pain. Passive Range of Motion Left: external rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; internal rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; and forward flexion normal, abduction normal, extension normal, and sudden ROM end-point with pain.
Special Tests: Special Tests Right: Jobes impingement sign at 80 deg negative and 130 deg negative; AC joint compression test negative and cross arm test negative; and Hawkins test negative, lateral impingement negative, Neer's test negative, Whipple's test negative, empty can sign negative, O'Brien's test negative, Speed test negative, Yergason's test negative, subscapularis strength test normal, and lift off test negative. Special Tests Left: Jobes impingement sign at 80 deg negative and 130 deg negative; AC joint compression test negative and cross arm test negative; and Hawkins test negative, lateral impingement negative, Neer's test negative, Whipple's test negative, empty can sign negative, O'Brien's test negative, Speed test negative, Yergason's test negative, subscapularis strength test normal, and lift off test negative.
Stability: Stability Right: no dislocation, laxity, or generalized joint laxity hand/elbow; anterior relocation test negative, apprehension test negative, and load and shift test negative; posterior apprehension test negative and load and shift test negative; and sulcus sign negative. Stability Left: no dislocation, laxity, or generalized joint laxity hand/elbow; anterior relocation test negative, apprehension test negative, and load and shift test negative; posterior apprehension test negative and load and shift test negative; and sulcus sign negative.
Neurovascularity:: Nerve Distribution for Motor and Sensory Components Right: axillary nerve intact, radial nerve intact, ulnar nerve intact, and median nerve intact. Nerve Distribution for Motor and Sensory Components Left: axillary nerve intact, radial nerve intact, ulnar nerve intact, and median nerve intact.
Neurological System: Coordination: finger-to-nose movement normal. Biceps Reflex Right: normal (2). Biceps Reflex Left: normal (2). Brachioradialis Reflex Right: normal (2). Brachioradialis Reflex Left: normal (2). Triceps Reflex Right: normal (2). Triceps Reflex Left: normal (2). Sensation on the Right: C5 normal, C6 normal, C7 normal, C8 normal, and T1 normal. Sensation on the Left: C5 normal, C6 normal, C7 normal, C8 normal, and T1 normal.
thanks
Ht: 5 ft 5 in Wt: 200 lbs BMI: 33.3 RR: 14 Document Review Discussed the following
Physical Exam Patient is a 74-year-old female.
Constitutional: General Appearance: healthy-appearing, NAD, and normal body habitus.
Psychiatric: Orientation: oriented to time, place, and person. Mood and Affect: normal mood and affect and active and alert.
Cardiovascular System: Arterial Pulses Right: radial normal, ulnar normal, and capillary refill test normal. Arterial Pulses Left: radial normal, ulnar normal, and capillary refill test normal. Edema Right: none. Edema Left: none.
Respiratory: Lungs: Clear to auscultation.
Skin: Right Upper Extremity: normal. Left Upper Extremity: normal.
C-Spine/Neck: Active Range of Motion: no crepitus or pain elicited by motion and flexion normal, extension normal, rotation normal, and lateral flexion normal. Passive Range of Motion: flexion normal, extension normal, rotation normal, and lateral flexion normal. Tests Left: quadrant test negative and Spurling's test negative.
Shoulder Inspection: Inspection Right: no erythema, induration, swelling, warmth, or long head of biceps deformity and AC prominence normal. Inspection Left: no erythema, induration, swelling, warmth, or long head biceps deformity and AC prominence normal.
Shoulder Palpation: Bony Palpation Right: no tenderness of the acromioclavicular joint, the bicipital groove, the greater tuberosity, the spine, the clavicle, the coracoid process, the suprasternal notch, the sternoclavicular joint, or the scapula. Bony Palpation Left: no tenderness of the spine, the clavicle, the coracoid process, the suprasternal notch, the sternoclavicular joint, or the scapula and tenderness of the acromioclavicular joint, the bicipital groove, and the greater tuberosity. Soft Tissue Palpation Right: no tenderness of the subacromial space or the rotator cuff insertion. Soft Tissue Palpation Left: no tenderness of the subacromial space or the rotator cuff insertion.
Shoulder Range of Motion: Active Range of Motion Right: external rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; internal rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; and forward flexion normal, abduction normal, extension normal, and no sudden ROM end-point with pain. Active Range of Motion Left: external rotation at 0 deg. of abduction 30 deg. and 90 deg. of abduction 30 deg.; forward flexion 60 deg., internal rotation at 90 deg. of abduction 30, abduction 60, extension 90 deg., and sudden ROM end-point with pain; and internal rotation at 0 deg. of abduction normal. Passive Range of Motion Right: external rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; internal rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; and forward flexion normal, abduction normal, extension normal, and no sudden ROM end-point with pain. Passive Range of Motion Left: external rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; internal rotation at 0 deg. of abduction normal and 90 deg. of abduction normal; and forward flexion normal, abduction normal, extension normal, and sudden ROM end-point with pain.
Special Tests: Special Tests Right: Jobes impingement sign at 80 deg negative and 130 deg negative; AC joint compression test negative and cross arm test negative; and Hawkins test negative, lateral impingement negative, Neer's test negative, Whipple's test negative, empty can sign negative, O'Brien's test negative, Speed test negative, Yergason's test negative, subscapularis strength test normal, and lift off test negative. Special Tests Left: Jobes impingement sign at 80 deg negative and 130 deg negative; AC joint compression test negative and cross arm test negative; and Hawkins test negative, lateral impingement negative, Neer's test negative, Whipple's test negative, empty can sign negative, O'Brien's test negative, Speed test negative, Yergason's test negative, subscapularis strength test normal, and lift off test negative.
Stability: Stability Right: no dislocation, laxity, or generalized joint laxity hand/elbow; anterior relocation test negative, apprehension test negative, and load and shift test negative; posterior apprehension test negative and load and shift test negative; and sulcus sign negative. Stability Left: no dislocation, laxity, or generalized joint laxity hand/elbow; anterior relocation test negative, apprehension test negative, and load and shift test negative; posterior apprehension test negative and load and shift test negative; and sulcus sign negative.
Neurovascularity:: Nerve Distribution for Motor and Sensory Components Right: axillary nerve intact, radial nerve intact, ulnar nerve intact, and median nerve intact. Nerve Distribution for Motor and Sensory Components Left: axillary nerve intact, radial nerve intact, ulnar nerve intact, and median nerve intact.
Neurological System: Coordination: finger-to-nose movement normal. Biceps Reflex Right: normal (2). Biceps Reflex Left: normal (2). Brachioradialis Reflex Right: normal (2). Brachioradialis Reflex Left: normal (2). Triceps Reflex Right: normal (2). Triceps Reflex Left: normal (2). Sensation on the Right: C5 normal, C6 normal, C7 normal, C8 normal, and T1 normal. Sensation on the Left: C5 normal, C6 normal, C7 normal, C8 normal, and T1 normal.